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How do I ensure a provider’s clinical documentation and coding are as accurate as possible?

  • When educating providers on best practices for risk adjustment documentation, Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I (“4 Key Areas to Risk Adjustment Documentation”), says it’s best to focus on a few key areas:
    • Make sure problem lists are kept up to date. The problem list should show the status of each condition (e.g., active, chronic, or resolved). It should not be a laundry list of every condition the patient has ever experienced. When updating the problem list, make sure the highest level of specificity known to the provider is captured in the diagnosis codes. Problem lists should not contain only default unspecified codes: these codes do not accurately show the true severity of illness.
    • All problems need to be in the assessment. All problems assessed during the visit should be noted in the assessment portion of the record and coded accordingly. Don’t limit the diagnosis codes on the claim to only what brought the patient into the office that day.
    • All diagnoses should be documented. All diagnoses that were part of the provider’s medical decision-making process should be documented. An example is a patient who is being treated with a medication that may affect the treatment of the current, presenting issue. If it affects how the current condition is treated, it should be documented and coded.
    • All chronic conditions documented at least once, annually. All of the patient’s chronic conditions should be assessed during a face-to-face encounter, at least annually, and submitted on a claim. This includes status codes such as amputations, transplant status, ostomies, etc.
  • Suggested reading: "HCC Coders Find Surprises in Coding Clinic for ICD-10," by Sheri Poe Bernard
  • AAPC offers a Risk Adjustment Coder Bundle, designed especially for the needs of risk adjustment coders.
  • AAPC also offers the Certified Risk Adjustment Coder (CRC) credential. As a CRC, you will have confidence in your ability to read medical charts and to assign correct diagnosis codes for HCCs and other risk adjustment models. Take the CRC Preparation Course to increase your chances of success in passing the CRC exam.

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